Case 4 - A Child With Chronic Constipation And Pica

The Patient"This
is my son Bobby, he is 5 years old. He's always been a pretty normal
kid. He likes to play outside, sometimes alone and sometimes with his
2 sisters, and he knows everything there is about Power Rangers. His
development has always been pretty normal. I work in finance, and my
wife is a learning disabilities teacher. We live in an older home in
a small Iowa town."

The Problem / Clinical Presentation"Bobby
has had a long history of bowel problems. About 2-1/2 years ago, we
noticed that he was constipated a lot. He'd have regular movements,
then an hour later runny stools or nothing at all for days. We took
him to his pediatrician and checked all sorts of things. They tried
to give him different medicines, and they tried some behavior
therapy, but nothing seemed to help. Then we took him to a specialist
about a year ago. Bobby had to go to the hospital a few times to
clean him out when he got all plugged up. About a week ago, he was
really plugged up and his pediatrician took an x-ray. After the x-ray
the doctor asked us questions about the house and if Bobby ever ate
things he shouldn't. My wife mentioned that she'd seen Bobby peeling
paint and wallpaper off the walls over the last year but she never
saw him put it in his mouth. The doctor did some tests and sent us to
the University of Iowa because they were abnormal."

Clinical Physical Exam
Bobby was somewhat pale but in no acute distress. His vital signs
were normal and stable. He had a height of 109 cm (30th percentile)
and weight of 18.2 kg (50th percentile). HEENT was unremarkable.
Cardiovascular exam showed a regular rate and rhythm with a Grade
I/VI systolic ejection murmur consistent with a flow murmur. Lungs
were clear to auscultation bilaterally. The abdomen was soft and
nontender and slightly distended with stool palpable in the left
lower quadrant. Genitourinary examination was normal with a rectal
exam showing decreased tone and a large rectal vault filled with lots
of soft stool. Several small bruises were on the skin. Neurologic
examination showed normal deep tendon reflexes throughout with normal
tone sensation, and ability to tip toe, heel walk and squat.

Clinical Differential Diagnosis

The differential diagnosis for a 5 year old with constipation
would include:

Imaging FindingsRadiopaque
densities were noted in the colon. Dense transverse metaphyseal bands
were noted on plain radiographs of the wrist.

Imaging Differential Diagnosis
Dense transverse metaphyseal bands are most commonly seen in lead
poisoning. They can also be a normal finding in children 2-6 years
old.

Operative Intervention
No operative intervention was performed

Pathological Findings
Not applicable

Pathological Diagnosis
Not applicable

Treatment Course, Prognosis and Follow-up
Since Bobby had a lead level of >70 ug/dl, he was admitted for
inpatient chelation therapy with Dimercaprol (BAL) and calcium EDTA.
He also received Go-LYTELY for bowel evacuation of lead in his stool.

"We were really surprised when the doctors said Bobby had a high
lead level. Thinking back, I remember noticing some white flakes once
when he had a bowel movement, but I thought it was maybe left over
from a barium test he had one time. My wife even had the paint
upstairs tested for lead before, and it was okay. The state medical
health department ran some new tests on our house, our water and the
soil around the house. My daughters had their lead levels tested too,
we're waiting on all the results."

"The doctors mentioned that lead could cause some behavior
changes. Bobby's in preschool, and he's been doing pretty well until
a few months ago, when his teachers mentioned some increased
grumpiness and temper problems and that he's been kind of irritable."

"They said he had a lot of lead in him and they started therapy to
get the lead out. They gave him some medicine to clean out his bowels
since there were still paint chips you could see on the x-ray. Then
he got another medicine to get it out of his blood and his bones. We
can't go back to our home until we get the results of the Health
Department's tests, and Bobby probably will still need to take
medicine at home. The doctors told us when he finished his treatment
and the lead is gone, he'll be okay."

The Approach to the Child With an Ingestion

Ingestions can be accidental or intentional. The natural curiosity
of young children often will lead to ingestions of inert or noxious
materials and substances (e.g. such as paper, small toys,
medications, etc.). Inadvertent ingestion of appropriate medications
also occurs by taking of the wrong amount or too frequent dosing of a
prescribed medication. Intentional ingestion occurs because of a
suicide attempt or gesture, Munchausen Syndrome, or Munchausen
Syndrome by proxy.

Ingestions may be acute or chronic. In general, acute ingestions
may be more life threatening, while chronic ingestion carry more
morbidity. A chronic ingestion may be life threatening and acute
ingestions may carry lifelong morbidities depending on the toxin
ingested.

Differential Diagnosis
The differential diagnosis is extremely extensive and includes many
medications, plant materials, and numerous organic and inorganic
toxins.

History and Physical
The history of an acute ingestion is often easier to take because the
events are recent. The history elicited from the child or family
members should include

The identity or suspected identity of the toxin or toxins

Their concentration,

The potential amount ingested (ie. how many pills in bottle
and how many left in bottle or on floor, etc)

The time course,

Symptoms since ingestion

Any treatments administered

Unstable patients should also have an emergent history taken while
treatment is being administered (mnemonic is AMPLE - Allergies,
Medications taken, Past medical history, Last meal, Events).

Histories concerning chronic ingestions are often more difficult
to obtain. The toxin may not be recognized as a noxious substance or
the amount taken regarded as trivial and not important to mention to
the health care provider. The ingestion may also not be seen by a
caretaker or it may be due to occupational or recreational exposure
(e.g. Mercury poisoning in the making of hats or by exposure in a
laboratory, or lead exposure in glass making).

A complete physical examination is also important, with attention
to subtle changes in vital signs, eyes, and skin, and odors from the
patient. The specific physical signs seen on the physical examination
will be different depending on the toxin ingested. The cardiovascular
and neurologic status should receive the highest priority in
evaluation.

Evaluation
Laboratory evaluation of an acute ingestion coincides with obtaining
the history and physical and treatment of the patient. Samples of
body fluids should be obtained including blood and urine toxicology
screenings, as well as gastric lavage samples if appropriate. Samples
of plants, insects or other materials may be sent to the appropriate
laboratory or professional for identification. Radiographs may be
helpful if a radiopaque toxin is suspected. Toxin identification
accuracy is improved when clinical information is submitted along
with the samples.

Chronic ingestion testing for potential toxins suggested by a
careful history and physical examination should be undertaken as is
appropriate (e.g. Lead testing in a 9 month old who has lead based
paint in the living environment).

Treatment
Management of acute and chronic ingestions includes five principles:

Removal from continued exposure to the toxin

Stabilize the patient

Enhance excretion/removal of the toxin from the patient

Use of antidote if one is available

Apply safety/prevention strategies to patient, family, and
home environment

Removal from continued exposure can be easy (e.g. remove patient
from carbon monoxide infiltrated room) or difficult (e.g. find the
lead source in a patient whose home has tested negative).

The patient should be stabilized using the "ABC" management
strategy for all emergently treated patients even if it is a chronic
ingestion.

Enhancing the excretion or removal of the toxin from the patient
depends on the toxin and the patient's condition. These strategies
may include inducing emesis or diarrhea, use of activated charcoal to
absorb the toxin in the gastrointestinal tract and bloodstream,
acidification/alkalinization of the urine, diuresis, and dialysis or
hemoperfusion.

Relatively few toxins have specific antidotes when one considers
the number of potential toxins. These antidotes may have toxic side
effects themselves so they need to be used appropriately.

Safety and prevention strategies should be stressed, such as
keeping medications in resistant packaging, locked up and away from
children, keeping smaller amounts of medication available in the
home, choosing non-poisonous plants for landscaping, routine home
maintenance such as having the furnace inspected and use of carbon
monoxide detectors in the home, and most importantly, routine
education about potential problems for families during well child
visits.

Lead Intoxication Discussion

Clinical Presentation
A complete history including specific lead exposure is key to the
diagnosis. The physical exam is rarely helpful. Many children with
elevated lead levels are asymptomatic. Vague, nonspecific symptoms
may include myalgia, fatigue, irritability, lethargy, abdominal
discomfort, decreased concentration, headache, tremor, vomiting or
weight loss.

Pathophysiology
Almost all U.S. children are at risk for lead poisoning. Lead can be
toxic to children for several reasons. Lead can enter the CNS more
easily in children than adults because the blood-brain barrier is not
well-developed. Lead has a higher bioavailability in children than in
adults. In addition, childhood behaviors like repetitive
hand-to-mouth activity and pica predispose the child to ingestion.

Lead is absorbed through the GI tract and the lungs. The most
common source of lead poisoning in children is through lead-based
paint, which is frequently found in older and many inner-city
homes.
Lead tastes sweet, which is why children start and continue to put it
in their mouths. Other sources of lead include contaminated soil and
dust, tap water, occupational or recreational exposure, airborne
lead, and imported or improperly stored food.

Lead interferes with the incorporation of iron into the heme
molecule, causing a microcytic, hypochromic anemia with basophilic
stippling. Children with lead poisoning are prone to neurotoxicity,
although the mechanism is not well understood. Peripheral neuropathy,
renal failure and gastrointestinal problems in adults are all
associated with lead intoxication.

Lab Findings
A CBC should be obtained along with a peripheral smear to evaluate
anemia and basophilic stippling.
BUN, creatinine and urinalysis are helpful in assessing renal damage.
Serum ferritin, TIBC and Fe saturation should also be considered to
check for iron deficiency.

Imaging FindingsAbdominal
radiographs can identify lead particles in the gut, a sign of acute
lead ingestion. Radiographs of long bones may show lines of increased
density at the metaphyseal plate as a result of growth arrest, due to
chronic lead ingestion.

Pathology
Not applicable

Differential Diagnosis

Iron deficiency anemia

Heavy metals intoxication

Treatment
All cases of lead poisoning must be reported to the local health
department. An inspection of the home and surroundings will follow
with decontamination as indicated. Family members should be screened
and counseled on how to decrease lead exposure. Chelation therapy is
indicated and may be done inpatient with Dimercaprol and/or calcium
EDTA for levels >45 ug/dl or outpatient with Succimer (DMSA). If
the child's level is between 10-45 ug/dl, parental education,
environmental investigation and treatment of iron deficiency anemia
is indicated. At these levels, effectiveness of chelation is
questionable. After the initial therapy, blood lead levels should be
closely monitored. Depending on the duration of exposure, more than
one round of chelation therapy may be necessary. Regular follow-up
screening is mandatory.

Prognosis
The prognosis for a child with lead intoxication depends on his/her
lead level and duration of exposure. The overall effects are
difficult to determine for an individual child since the effects on
the central nervous system may not show up for years.

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The information contained in Virtual Pediatric Hospital is not a substitute for the medical care and advice of your physician. There may be variations in treatment that your physician may recommend based on individual facts and circumstances.